J. Agric. Food Chem.

2011, 59, 777–784 777

DOI:10.1021/jf103846u

Chemistry behind Vegetarianism

DUO LI*
Department of Food Science and Nutrition, Zhejiang University, 268 Kaixuan Road,
Hangzhou, China 310029

This review summarizes the effect of a habitual vegetarian diet on clinical complications in relation
to chemistry and biochemistry. Omnivores have a significantly higher cluster of cardiovascular risk
factors compared with vegetarians, including increased body mass index, waist to hip ratio, blood
pressure, plasma total cholesterol (TC), triacylglycerol and LDL-C levels, serum lipoprotein(a) con-
centration, plasma factor VII activity, ratios of TC/HDL-C, LDL-C/HDL-C and TAG/HDL-C, and serum
ferritin levels. Compared with omnivores, vegetarians, especially vegans, have lower serum vitamin B12
concentration and n-3 polyunsaturated fatty acid (PUFA) levels in the tissue membrane phospholipids,
which are associated with increased collagen and ADP stimulated ex vivo whole blood platelet aggrega-
tion, plasma 11-dehydrothromboxane B2, and homocysteine levels and decreased plasma HDL-C. This
may be associated with an increased thrombotic and atherosclerotic risk. It is suggested that vegetarians,
especially vegans, should increase their dietary n-3 PUFA and vitamin B12 intakes.

KEYWORDS: Vegetarian; vitamin B12; n-3 PUFA; homocysteine; platelet aggregability

INTRODUCTION
Human beings originated in South Africa and then migrated to
different parts of the world approximately a hundred thousand
years ago. In the course of human evolution, six major genetic
clusters have been formed: Africa, Europe, Middle East, Central/
South Asia, East Asia and Oceania, and America (1). Human
beings are very similar in term of our genomes; however, there are
significant differences physically and physiologically, such as
body weight, height, eye/hair color, skin color, response to drug
treatments, dietary intake, and environmental factors. These
differences are caused mainly by environmental factors, of which
diet is the largest. An unanswered question has always been the
difference between omnivores and vegetarians who are descen-
dants of omnivores and vegetarians, respectively, who have both
come from the same ancestor in terms of phenotypic variation
and biochemistry? Unfortunately, there are no data available on
phenotypic variation between omnivores and vegetarians. In this
review, I will use available evidence to review the biochemistry
behind vegetarianism.
VEGETARIANS AND THEIR DIETS
Vegetarians state that their diet must exclude all animal flesh.
There are different varieties of vegetarianism, which exclude or
include various foods (2) (Table 1). Raw veganism includes only
fresh and uncooked fruit, nuts, seeds, and vegetables. Fruitarian-
ism permits only fruit, nuts, seeds, and other plant matter that can
be gathered without harming the plant. Su vegetarianism (such
as Buddhism in China) excludes all animal products as well as
vegetables in the Allium family such as onion, spring onion, garlic,
scallions, and leeks (3).
*Phone þ86-571-86971024; fax þ86-571-86971024; e-mail duoli@
zju.edu.cn.
Strict vegans and Su vegetarians also avoid products that may
use animal ingredients not included in their labels or which use
animal products in their manufacturing, for example, cheeses that
use animal rennet (enzymes from animal stomach lining), gelatin
(from animal skin, bones, and connective tissue), some sugars
that are whitened with bone char (e.g., cane sugar, but not beet
sugar), and alcohol clarified with gelatin or crushed shellfish and
sturgeon (3).
Some individuals claim themselves to be semivegetarian.
However, it is debated by most vegetarian groups because semi-
vegetarian diets include fish and other seafood, and poultry
sometimes, whereas it is stated that vegetarians must exclude all
animal flesh.
In general, compared with an omnivorous diet, vegetarian diets
are rich in fiber, magnesium, Fe3þ, folic acid, vitamins C and E,
n-6 polyunsaturated fatty acid (PUFA), phytochemicals, and
antioxidants but low in total fat, saturated fatty acid (SFA),
cholesterol, sodium, zinc, Fe2þ, vitamins A, B12, and D, and
especially n-3 PUFA (Table 2). Low intake of total fat, SFA, and
sodium and increased intake of fiber, phytochemicals, and anti-
oxidants in vegetarians is associated with decreased blood pres-
sure and body mass index (BMI). These factors are known to
reduce the risk of cardiovascular disease (CVD). However, there
is concern over whether vegetarians, and particularly vegans,
have an adequate intake of several important nutrients, particu-
larly Fe, Zn, vitamin B12, and n-3 PUFA.
MICRONUTRIENTS STATUS OF VEGETARIANS
Iron, zinc, and vitamin B12 are currently the micronutrients
of greatest concern when considering the nutritional value of
vegetarian diets.
Iron. Iron is an essential trace element for blood formation.
Most iron in the human body is found in hemoglobin and

© 2011 American Chemical Society Published on Web 01/04/2011 pubs.acs.org/JAFC

778 J. Agric. Food Chem., Vol. 59, No. 3, 2011
Table 1. Dietary Composition of Main Types of Vegetarianism
meat fish egg dairy honey Allium family
√
vegana   
√  
√ √
ovovegetarian   
√ √ √ vitamin C
lactovegetarian   
√ √ √ √
ovo-lactovegetarian  
raw veganb      
Su vegetarianc      
fruitariand      
a phytochemicals
Excludes all animal flesh and animal products, milk, honey, eggs. May also
exclude any products tested on animals, also any clothing from animals. b Includes
only fresh and uncooked fruit, nuts, seeds, and vegetables, excludes vegetables in
the Allium family. Vegetables can be cooked only up to a certain temperature.
c
Includes only fruit, nuts, seeds, and other plant matter that can be gathered without
harming the plant. d Excludes all animal products as well as vegetables in the Allium family.
myoglobin or occurs as part of enzymes in the energy-yielding
pathway. Iron deficiency is the most common mineral nutritional
deficiency globally, although vegetarians are not more likely to be
iron-deficient than omnivores.
Studies reported that vegetarians have iron intakes that are
significantly higher than (4, 5) or similar to (6-8) those of
omnivores in different populations. However, vegetarians have
a significantly lower serum ferritin concentration than omnivores.
Serum ferritin levels did not correlate with dietary iron intake
(5,7,9). Ferritin is a storage form of body iron. A small amount of
ferritin circulates in plasma, mostly as iron-free apoferritin.
Circulating ferritin is in equilibrium with tissue iron stores and,
under most circumstances, the concentration of serum ferritin
accurately reflects the levels of iron in the tissues. A low serum
ferritin concentration is usually diagnostic of iron deficiency.
Vegetarians, unlike omnivores, obtain most of their iron from
cereals, grains, nuts, seeds, vegetables, fruits, and bakery pro-
ducts, which are nonheme iron sources. Most nonheme iron from
vegetarian diets is in the ferric (Fe3þ) state, which is soluble at the
acidic pH of the stomach but becomes insoluble at the more
alkaline pH of the duodenum. Gastric acid converts Fe3þ to the
Fe2þ form when body iron stores are low and by the concomitant
ingestion of some dietary components such as ascorbic acid,
sugars, and amino acids that form iron chelates to increase iron
absorption (10). Moreover, bioavailability and absorption of
nonheme iron may be inhibited by certain dietary constituents
that are abundant in some vegetarian diets, such as oxalates in
vegetables and phytates in cereals and legumes (11,12), tannins in
tea and coffee (13), and possibly soy protein (14). Heme iron
comes mainly from seafood and meat, especially red meat, when it
is released from the surrounding polypeptide chain. Heme is
absorbed intact by the mucosal cell, where the porphyrin ring is
split and iron is liberated. It is absorbed more efficiently than
nonheme iron and is minimally affected by dietary factors, which
probably explains the lower iron status of vegetarians compared
with omnivores.
Zinc. Zn is an essential trace mineral that is a constituent of
more than 50 different enzymes involved in most metabolic
pathways and is important for protein metabolism, cell growth
and repair, and immune function (15).
Zinc is found in a wide range of foods, including protein foods
and plant foods such as legumes, whole grains, nuts, and seeds.
Zn from animal sources is more bioavailable than Zn from
plant foods. Protein, insoluble fiber, phytate, and some minerals,
for example, Fe, Ca, and P, can reduce Zn absorption. The
inhibiting effect of phytate on Zn absorption has been quanti-
fied by the phytate/zinc molar ratio. Low zinc bioavailability diets
(15% absorption) were listed as high in unrefined cereal grains, with
phytate/zinc ratios of >15, and the majority of energy was supplied
Li
Table 2. Chemical Characteristics of Vegetarian Diet
rich in chemicals low in chemicals
fiber vitamin A
vitamin B12
vitamin E vitamin D
folic acid zinc
magnesium iron
n-6 polyunsaturated fatty acid sodium
carbohydrate cholesterol
saturated fatty acids
n-3 polyunsaturated fatty acid
by high-phytate foods such as sorghum, peanuts, cowpeas, unlea-
vened bread, and unprocessed soybean protein concentrates (16).
Some food preparation techniques, such as leavening bread, soaking
and sprouting beans, grains, and seeds, could reduce binding of zinc
by phytate and increase zinc bioavailability (17, 18).
Because there is low zinc bioavailability in vegetarian diets,
vegetarians have lower status compared with omnivores. How-
ever, intake of zinc density is not significantly different between
vegetarians and omnivores (19-21). There is currently no agree-
ment on the best method to assess zinc status. Despite serum or
plasma, hair, and salivary Zn levels being used to assess Zn status,
all have shortcomings (22). No significant difference has been
seen between vegetarians and omnivores on serum/plasma zinc
concentrations (21, 23).
Vitamin B12. Vitamin B12 is essential for new cell synthesis,
blood formation, maintenance of the nervous system, etc. Of the
vitamins, B12 is the only one containing a mineral (cobalt); it also
known as the red vitamin. Seafood, animal meats, eggs, and liver
are good sources for vitamin B12. Vitamin B12 is not found in
plant foods; however, seaweed may contain vitamin B12 ana-
logues, which can be counted on as reliable sources of active
vitamin B12. Ovo-lactovegetarians may get vitamin B12 from eggs
and dairy products. Vegans could get some vitamin B12 from
seaweed, plants, and edible fungi (such as mushrooms) on farms
or in the wild, which may be contaminated from bacteria in the
soil (24). Evidence suggests that vegetarians, especially vegans,
who do not take vitamin B12 supplements often have abnormally
low serum concentrations of vitamin B12. Fortunately, human
beings require only tiny amounts of vitamin B12. Because the
human body conserves B12 and reuses it without destroying the
compound, and it can be synthesized by intestinal bacteria,
clinical evidence of vitamin B12 deficiency is uncommon.
Vegetarians have a lower vitamin B12 status compared with
omnivores. Serum vitamin B12 concentration decreased progres-
sively from the high-meat-eaters group (n = 18, >280 g of meat/
day) to the moderate-meat-eaters group (n = 60, <280 g of meat/
day) to ovo-lactovegetarians (n = 43) to vegans (n = 18) (p <
0.05) (20). Serum vitamin B12 concentration was significantly
correlated with plasma homocysteine (p < 0.05) in the study
subjects from Australia (25, 26). Similar results have also been
found in Britain (27) and in China (28). Chinese vegetarian
parents and their preschool children had similar serum vitamin
B12 and homocysteine concentrations; however, serum vitamin
B12 was not correlated with plasma homocysteine in the parents,
their children, or pooled parents and children (29).
Vitamin D. Vitamin D is rare in vegetarian diets; however, it
does not seem that ovo-lactovegetarians or vegans are more likely
to be deficient than omnivores because human beings can synthe-
size it. The body’s cholesterol can be converted into vitamin D
by ultraviolet irradiation from the sun. Fifteen minutes of skin
exposure a day during peak hours should be enough for fair-
skinned individuals, but those who have darker skin, are older,
Review
Figure 1. Metabolic pathway of 18:3n-3 to 22:6n-3. CE, chain elongation; CE, chain shortening reaction.
or who live at more northern latitudes might not get enough
exposure, especially in the winter (10).
MACRONUTRIENTS STATUS OF VEGETARIANS
There is no difference in carbohydrate sources between vege-
tarian and omnivorous diets. Despite the protein sources being
different between the two groups, dietary protein cannot be incor-
porated into human tissues. When we eat proteins from plant or
animal sources, the body must first alter them by breaking them
down via denaturation and hydrolysis into amino acids; only then
can it rearrange them into specific human body proteins. A
balanced vegetarian diet could provide sufficient protein to meet
physiological needs. However, this is not the case when it comes
to fat and fatty acids.
Fat and Fatty Acids Intake and Status of Vegetarians. The
predominant PUFA in the Western diet is linoleic acid (18:2n-6),
which is commonly found in vegetable seed oils. This is the parent
fatty acid of the n-6 series PUFA, which can be converted in vivo
to C20 and C22 n-6 long chain (LC) PUFA. R-Linolenic acid
(18:3n-3) is less abundant than 18:2n-6; however, it is also present
in vegetable oils and is the precursor of C20 and C22 n-3 LC
PUFA. Omnivores can obtain their C20 and C22 n-3 LC PUFA
either from dietary 18:3n-3 or directly from the consumption of
fish, eggs, or animal products. Ovo-lactovegetarians can gain a
limited amount of C20 and C22 n-3 LC PUFA from milk, dairy
products, and eggs. In contrast, vegans must rely totally on
endogenous synthesis from 18:3n-3 by desaturation and elonga-
tion (Figure 1). Because animals can convert 18:3n-3 to C20 and
C22 n-3 LC PUFA, and plants cannot, there are no C20 and C22
n-3 LC PUFA in plant-based vegan diets. Conversion of 18:3n-3 to
20:5n-3 and 22:6n-3 has relatively poor efficiency because a sub-
stantial proportion of the 18:3n-3 is diverted to β-oxidation (30).
A major rate-limiting step in 18:3n-3 conversion to 20:5n-3 and
other LC n-3 PUFA is considered to be the first Δ6 desaturation.
This is demonstrated effectively by consideration of data from
studies where 18:4n-3 is fed, which is the product of the Δ6
desaturation of 18:3n-3. The 20:5n-3 level of red blood cell
membrane phospholipid (PL) was significantly increased from
0.8 to 1.1% when 32 stroke patients consumed a black currant
seed oil (rich in stearidonic acid 18:4n-3 and γ-linolenic acid)
supplemented diet (7.5% black currant seed oil, 50% soybean oil,
and 42.5% medium-chain triacylglycerols (TAG)) for 3 weeks
compared with a 100% soybean oil diet and a 50% soybean oil þ
50% medium-chain TAG diet (31). In another study, the 20:5n-3
levels of TAG, cholesteryl ester, and PL of guinea pig liver were
J. Agric. Food Chem., Vol. 59, No. 3, 2011 779
significantly higher after guinea pigs were fed a diet containing
10% black currant seed oil for 40 days compared with the diet
containing 10% walnut oil (18:3n-3 containing) (32). A similar
result has also been found in rats (33). Dietary sources of stearidonic
acid (black currant seed oil, alpine currant seed oil, and oil from
Echium species) might be a viable source of LC n-3 PUFA, parti-
cularly for vegetarian groups. Because the formation of 22:6n-3
from 22:5n-3 also requires a Δ6 desaturase, it is likely that none of
the intermediate n-3 PUFA (18:3-22:5) will be as effective a
source of tissue of 22:6n-3 compared with dietary 22:6n-3 (on a
gram for gram basis). In addition, 18:2n-6, a precursor of 20:4n-6,
the major dietary PUFA, is a competitive inhibitor of the metab-
olism of 18:3n-3 to 18:4n-3 (30). Furthermore, diets rich in 18:2n-6
decrease the expression of the hepatic Δ6 desaturase compared
with fat-free diets, which presumably also reduces the possibility of
conversion of 18:3n-3 to 18:4n-3 and 24:5n-3 to 24:6n-3 (34).
Is there a decreased n-3 PUFA status in vegetarian popula-
tions? Is there any association between n-3 PUFA status and
clinical complications? These questions are further explored in the
following sections.
n-3 PUFA Status in Vegetarians. One hundred and thirty-nine
healthy male subjects aged 20-55 years participated in an obser-
vational study. According to subjects’ habitual dietary intake
(based on the semiquantitative Food Frequency Questionnaire
(FFQ)), they were divided into four groups, vegan, ovo-lactove-
getarian, moderate meat eater, and high meat eater. The proportion
of total n-3 PUFA, 20:5 n-3, 22:5 n-3, and 22:6 n-3 and n-3 to n-6
ratio were significantly lower and the 20:4n-6 to 22:5n-3 ratio was
significantly higher in both the ovo-lactovegetarian and the vegan
groups than in both the high- and moderate-meat-eater groups in
the plasma PL. The proportions of 20:5n-3, 22:5n-3, 22:6n-3, and
total n-3 PUFA and ratio of n-3 to n-6 were significantly lower in the
vegan group than in the ovo-lactovegetarian and high- and mod-
erate-meat-eater groups in the platelet PL (35). In another cross-
sectional study, 50 free-living healthy female vegetarians and 24 sex-
and age-matched omnivores participated in the study. Compared
with the omnivores, the vegetarians had significantly lower con-
centrations of 20:3n-6, 20:4n-6, 22:5n-6, 20:5n-3, 22:6n-3, total n-6,
and n-3 PUFA and ratio of n-3/n-6 PUFA in serum PL (36).
A cross-sectional study from the United Kingdom involved
659 male subjects, of which 196 were omnivores, 231 vegetar-
iansm, and 232 vegans. The proportions of 20:5n-3 and 22:6n-6 in
plasma were significantly lower in the vegetarians and vegans than
in the omnivores (p < 0.001), whereas 22:5n-3 was signifi-
cantly lower in the vegans than in the meat eaters (p < 0.05).
780 J. Agric. Food Chem., Vol. 59, No. 3, 2011
Figure 2. Relationship between thrombosis and metabolites of 20:4n-3 and 20:5n-5.
Proportions of 20:5n-3, 22:5n-3, and 22:6n-6 in plasma were
not significantly associated with the duration of time since
the subjects became vegetarian or vegan, which ranged from <1
to >20 years (37).
A recent observational study from Austria involved 98 adult
subjects, of which 23 were omnivores, 25 vegetarians, 37 vegans,
and 13 semiomnivores. Erythrocyte proportions of 20:5n-3,
C22:5n-3, C22:6n-3, and total n-3 fatty acids in sphingo- and
phospholipids (SPL), phosphatidylcholine (PC), phosphatidyl-
serine (PS), phosphatidylethanolamine (PE) was significantly
lower in vegan and vegetarian groups compared with omnivores
and semiomnivores (38).
Is there any association between decreased n-3 PUFA status
and clinical complication in vegetarians?
RELATIONSHIP BETWEEN n-3 PUFA STATUS AND PLATE-
LET FUNCTION IN VEGETARIANS
Collagen- and adenosine-50 -diphosphate (ADP)-stimulated ex
vivo whole blood platelet aggregation were significantly higher in
both vegetarian and vegan groups than in both high- and
moderate-meat-eater groups. The vegan group had a significantly
higher mean platelet volume (MPV) than the high- and moderate-
meat-eater and ovo-lactovegetarian groups (35). Increased MPV
in vegans suggests the presence of larger, activated platelets.
Evidence from case control studies has indicated that an increased
MPV is an independent risk factor for acute myocardial infarction
(MI) (39) and for acute and/or nonacute cerebral ischemia (40).
Large platelets, in such cases, have been shown to have increased
reactivity. When platelets become activated, they change from
their normal resting disk-like structure to assume a spherical
shape and their volume increases substantially, leading to the
potential for thrombus formation. In a multiple linear regression
analysis, after controlling for potential confounding factors such
as dietary group, age, exercise, body mass index, and dietary PUFA
and saturated fat, cholesterol, carbohydrate, and fiber intake, the
MPV was still strongly negatively correlated with platelet PL 20:
3n-6 (p = 0.003) and 22:5n-3 (p =0.001). The data suggest that
22:5n-3 and 20:3n-6 may play a role in the structural function of the
platelet membrane (41). This, in conjunction with the increased
Li
platelet aggregability, suggests what should be an increased
thrombosis tendency in vegans, and in the case of the platelet
aggregation is associated with low dietary intake of n-3 PUFA.
Most acute clinical cases of cardiovascular disease are caused
by the formation of a thrombus, with platelet aggregation being
the initial step in these events (42). Increased platelet aggregability
is significantly associated with CHD mortality (43). Fisher et al.
(44) reported that there was no significant difference between the
vegetarians and the omnivores on ex vivo collagen-, arachidonic
acids (AA)-, ADP-, and epinephrine-stimulated platelet aggrega-
tion. However, Fisher et al. (44) used different methodology from
that used by Li et al. (35); they used the traditional optical method
for platelet aggregation test (using plasma), and they also adjusted
the platelet count. It has been reported that dilution of platelet-
rich plasma can cause changes in platelet responsiveness (43).
In an intervention study, ADP, epinephrin, collagen and ara-
chidonic acid induced platelet aggregation in both maximum
percentage or slope were significantly reduced after 10 vegetarians
were supplemented with 700 mg/day of each 20:5n-3 and 22:6n-3
for 8 weeks. Both 20:5n-3 and 22:6n-3 were significantly incor-
porated into plasma lipids (45).
Platelet aggregation is initiated by thromboxane A2 (TXA2), a
potent platelet aggregation agent and vascular contractor, pro-
duced from 20:4n-6 in the platelet membrane (46, 47). 20:5n-3 is
released from phospholipids of the platelet membrane and acts as a
“false” substrate to compete with 20:4n-6 for access to cyclooxy-
genase and produces an alternative form of thromboxane (TXA3),
which is relatively inactive in promoting platelet aggregation and
vasoconstriction (48). This situation can lead to a reduced TXA2
production and thus a lower thrombosis tendency (49, 50). A
vegetarian diet with a high n-6 to n-3 PUFA ratio can cause a high
tissue n-6 to n-3 PUFA ratio, that is, and increased 20:4n-6 to
20:5n-3 ratio, which may promote production of TXA2, leading to
increased platelet aggregability (35) (Figures 2 and 3).
PLASMA HOMOCYSTEINE CONCENTRATIONS IN VEGE-
TARIANS
It has been suggested that an increased plasma homocysteine
(Hcy) level is an independent risk factor for cardiovascular
 Review

Figure 3. Biosynthetic pathways of 20:4n-6- and 20:5n-3-derived eicosanoids. The binding of a stimulant (e.g., a glucocorticosteroid) to a membrane receptor results in the activation of phospholipase A2, which cleaves
20:4n-6 and 20:5n-3 from membrane phosphatidylcholine. After they are released from membrane phospholipids, free 20:4n-6 and 20:5n-3 can be metabolized by various enzyme systems to form a range of biologically
active eicosanoids. The eicosanoids from 20:5n-3 are generally less potent than the 20:4n-6-derived metabolites that compete with 20:5n-3 for the enzymes. The nature of the products formed depends on the tissue.
Abbreviations: PG, prostaglandin; TXA, thromboxane; LT, leukotrienes; LX, lipoxin; HPETE, hydroperoxyeicosatetraenoic acid; HPEPE, hydroperoxyeicosapentaenoic acid; HEPE, hydroxyeicosapentaenoic acid.
J. Agric. Food Chem., Vol. 59, No. 3, 2011
781
782 J. Agric. Food Chem., Vol. 59, No. 3, 2011 Li

Figure 4. Speculated effect of n-3 PUFA on homocysteine metabolic pathway. Abbreviations: ATP, adenosine triphosphate; 5,10-CH3-THF, 5,10-methyl-
enetetrahydrofolate; 5-CH3-THF, 5-methyltetrahydrofolate; BHMT, betainehomocysteine methyltransferase; CBS, cystathionine β-synthase; CSE, cystathio-
nine γ-lyase; MAT, methionine adenosyl transferase; MS, methionine synthetase; MTHFR, 5-methyltetrahydrofolate reductase; SAHH, S-adenosylhomo-
cysteine hydrolases; SH, serine hydroxymethyl transferase; DR, dihydrofolate reductase; SAM, S-adenosylmethione; SAH, S-adenosylhomocysteine; THF,
tetrahydrofolate; DHF, dihydrofolate; dTMP, 20 -deoxythymidine-50 -monophosphate; dUMP, 20 -deoxyuridine-50 -monophosphate; Pi, orthophosphate; PPi,
pyrophosphate.

diseases (51-53). Hcy is an intermediate metabolite in the
metabolism of methionine to cysteine. The normal metabolism
of Hcy involves two pathways: remethylation and transsulfura-
tion. Remethylation of Hcy to methionine requires vitamin B12
(methylcobalamin form) as a coenzyme for Hcy methyltransfer-
ase (methionine synthetase) and N5-methyltetrahydrofolate as
a methyl donor. The transsulfuration pathway of Hcy to cysteine
requires vitamin B6 as a coenzyme for both cystathionine
β-synthase (converts Hcy to cystathionine) and cystathionine
lyase (converts cystathionine to cysteine). A lack of dietary
vitamin B12 and/or folic acid or vitamin B6 results in elevation
of plasma Hcy (54) (Figure 4).
Vegans and ovo-lactovegetarians had significantly higher
mean plasma Hcy levels than omnivores, and plasma Hcy con-
centration was significantly negatively correlated with serum/
plasma vitamin B12 concentration (25, 28, 55, 56). Plasma Hcy
concentration was significantly negatively correlated with plasma
phospholipid concentration of PUFA 20:5n-3 (r = -0.226, p =
0.009), 22:5n-3 (r = -0.182, p = 0.036), 22:6n-3 (r = -0.286,
p=0.001), and total n-3 (r=-0.270, p=0.002) and the ratio n-3/
n-6 PUFA (r = -0.265, p = 0.002) and significantly positively
correlated with 20:4n-6 (r = 0.180, p = 0.037). In the partial
correlation analysis, after controlling for serum vitamin B12 and
folate concentrations, plasma Hcy was significantly negatively
correlated with plasma phospholipid concentration of 22:6n-3
(r=-0.205, p=0.019) and total n-3 (r=-0.182, p=0.038) and the
ratio n-3/n-6 PUFA (r=-0.174, p=0.048) (57). We have also
found a similar result in middle-aged and geriatric hyperlipidemia
patients (50 males, 31 females) and 65 healthy subjects (43 males,
22 females). Plasma Hcy demonstrated significant positive correlation
with adrenic acid (22:4n-6) (r = 0.188, p = 0.018) and negative
correlation with 22:6n-3 (r=-0.277, p=0.001) and the ratio of n-3/
n-6 (r = -0. 231, p = 0.003) in sex-, age- and BMI-controlled
partial correlation analysis (58). Erythrocyte 22:6n-3 levels were
significantly negatively correlated with plasma Hcy levels in 49 pre-
eclamptic subjects (59) (p < 0.01).
Plasma Hcy was significantly decreased in 150 patients with
acute myocardial infarction after 1 year of n-3 PUFA treatment
(containing 850-882 mg of 20:5n-3 and 22:6n-3) (p < 0.05) (60),
in 81 type 2 diabetic patients after n-3 PUFA supplements (3 g/
day) for 2 months (61), and in 24 diabetic dyslipidemia patients
after 3 months of n-3 PUFA supplementation (3.6 g/day, contain-
ing 57.4% of 20:5n-3 and 28.7% of 22:6n-3) with a statin-fibrate
combination (p < 0.01) (62). This may be another beneficial
effect of n-3 PUFA.
The mechanism of the n-3 PUFA decrease of plasma Hcy has
been explained by the effect of n-3 PUFA on enzyme activity and
gene expression involved in Hcy metabolism. Methionine adenosyl-
transferase (MAT) activity was significantly increased and
cystathionine-γ-lyase (CSE) activity was also increased, but
statistically insignificant, and mRNA expression of MAT and CSE
were significantly up-regulated when Sprague-Dawley rats were
fed tuna oil (containing 55% of 22:6n-3) for 8 weeks compared
with olive oil (63). The resultant increase in S-adenosylmeth-
ionine (SAM) synthesis by MAT would have also stimulated
S-adenosylhomocysteine (SAH) production, with the consequential
increased methyl transfer to various products. SAM serves primarily
as a universal methyl donor to a variety of acceptors (64). SAM,
as a cosubstrate, can react with a large variety of nucleophilic
acceptors by various methyltransferases. Proteins, nucleic acids,
Review
Table 3. Relative Benefits and Risks of Vegetarianism Compared with Omnivore
benefits risks
BMI homocysteine
waist/hip ratio platelet aggregability
blood pressure mean platelet volume
blood coagulation factor VII activity iron deficiency anemia
total cholesterol vitamin B12 deficiency anemia
(possible for children)
LDL-C
TAG
lipids, and xenobiotics can be methylated by these enzymes,
changing their mRNA expression, activity, function, or the pro-
cess in which they are involved (65). Increased MAT activity and
up-regulated MAT mRNA expression increases cystathionine
β-synthase (CBS) activity to provide some protection against the
toxic accumulation of Hcy and SAH (66, 67) and also accelerates
the permanent removal of Hcy from the methionine cycle by CBS.
It has also been shown that increased levels of SAH as an
activator up-regulate CBS (68) and as an allosteric inhibitor
down-regulate methylenetetrahydrofolate reductase (MTHFR),
suppress the synthesis of an important substrate (N5-methylte-
trahydrofolate, 5-CH3-THF) required for remethylation, and
promote the initial reaction of transsulfuration (cystathionine
synthesis) (64, 69). In CBS-expressing cells, these regulatory
functions would expedite permanent removal of Hcy and reduce
remethylation with some normalization of one-carbon flow (67).
All of the above issues may be associated with an increased
thrombotic and atherosclerotic risk in vegetarians, especially
vegans. However, meat eaters have a cluster of thrombotic and
atherosclerotic risk factors higher than those of both ovo-lacto-
vegetarians and vegans. These factors include BMI, waist/hip
ratio, blood pressure, coagulation factor VII activity, plasma TC,
LDL-C and TAG concentrations, ratios of TC/HDL-C, LDL-C/
HDL-C, and TAG/HDL-C, and serum ferritin levels (Table 3).
CONCLUSION
On the basis of the present data, it is suggested that vegetarians,
especially vegans, could benefit from increased dietary intake of
n-3 PUFA and vitamin B12 and thus improve the balance ratio of
n-3 to n-6 PUFA and vitamin B12 status, which may reduce any
thrombotic tendency that might increase their generally low risk
of cardiovascular disease.
LITERATURE CITED
(1) Rosenberg, N. A.; Pritchard, J. K.; Weber, J. L.; Cann, H. M.; Kidd,
K. K.; Zhivotovsky, L. A.; Feldman, M. W. Genetic structure of
human populations. Science 2002, 20, 2381-2385.
(2) Mangels, A. R. Position of the American Dietetic Association:
Vegetarian Diets. J. Am. Diet. Assoc. 2009, 109, 1266-1282.
(3) Wikipedia. Vegetarianism. At http://en.wikipedia.org/wiki/Vegetarianism
(accessed Sept 9, 2010).
(4) Yen, C. E.; Yen, C. H.; Huang, M. C.; Cheng, C. H.; Huang, Y. C.
Dietary intake and nutritional status of vegetarian and omnivorous
preschool children and their parents in Taiwan. Nutr. Res. (N.Y.)
2008, 28, 430-436.
(5) Harvey, L. J.; Armah, C. N.; Dainty, J. R.; Foxall, R. J.; Lewis, D. J.;
Langford, N. J.; Fairweather-Tait, S. J. Impact of menstrual blood
loss and diet on iron de_ciency among women in the U.K. Br. J.
Nutr. 2005, 94, 557-564.
(6) Reddy, S.; Sanders, T. A. Hematological studies on pre-menopausal
Indian and Caucasian vegetarians compared with Caucasian omni-
vores. Br. J. Nutr. 1990, 64, 331-338.
(7) Worthington Roberts, B. S.; Breskin, M. W.; Monsen, E. R. Iron
status of premenopausal women in a university community and its
J. Agric. Food Chem., Vol. 59, No. 3, 2011 783
relationship to habitual dietary sources of protein. Am. J. Clin. Nutr.
1988, 47, 275-279.
(8) Ball, M. J.; Bartlett, M. A. Dietary intake and iron status of
Australian vegetarian women. Am. J. Clin. Nutr. 1999, 70, 353-358.
(9) Faber, M.; Gouws, E.; Benade, A. J.; Labadarios, D. Anthro-
pometric measurements, dietary intake and biochemical data of
South African lacto-ovovegetarians. S. Afr. Med. J. 1986, 69,
733-738.
(10) Li, D. Food Nutrition; Light Industry Press: Beijing, China, 2010;
ISBN-978-7-122-09185-7.
(11) Ma, G.; Jin, Y.; Piao, J.; Kok, F.; Guusje, B.; Jacobsen, E. Phytate,
calcium, iron, and zinc contents and their molar ratios in foods com-
monly consumed in China. J. Agric. Food Chem. 2005, 53, 10285-10290.
(12) Siener, R.; Hönow, R.; Voss, S.; Seidler, A.; Hesse, A. Oxalate
content of cereals and cereal products. J. Agric. Food Chem. 2006, 54,
3008-3011.
(13) Hallberg, L.; Rossander., L. Effect of different drinks on the
absorption of non-heme iron from composite meals. Hum. Nutr.
Appl. Nutr. 1982, 36, 116-23.
(14) Lynch, S. R.; Dassenko, S. A.; Morck, T. A.; Beard, J. L.; Cook,
J. D. Soy protein products and heme iron absorption in humans. Am.
J. Clin. Nutr. 1985, 41, 13-20.
(15) World Health Organization, Food and Agricultural Organization of
the United Nations. Vitamin and Mineral Requirements in Human
Nutrition; Sun Fung Printing: China, 2004; ISBN: 92-4-154612-3.
(16) Gibson, R. S. Content and bioavailability of trace elements in
vegetarian diets. Am. J. Clin. Nutr. 1994, 59, 1223S-1232S.
(17) Agte, V. V.; Joshi, S. R. Effect of traditional food processing on
phytate degradation in wheat and millets. J. Agric. Food Chem. 1997,
45, 1659-1661.
(18) Hambidge, K. M.; Miller, L. V.; Westcott., J. E.; Sheng, X.; Krebs,
N. F. Zinc bioavailability and homeostasis. Am. J. Clin. Nutr. 2010,
91, 1478S-1483S.
(19) Ball, M. J.; Ackland, M. L. Zinc intake and status in Australian
vegetarians. Br. J. Nutr. 2000, 83, 27-33.
(20) Li, D.; Sinclair, A. J.; Mann, N.; Turner, A.; Ball, M. Selected
micronutrients intakes and status in men with differing meat intakes,
vegetarians and vegans. Asia Pac. J. Clin. Nutr. 2000, 9, 18-23.
(21) Yen, C. E.; Yen, C. H.; Huang, M. C.; Cheng, C. H.; Huang, Y. C.
Dietary intake and nutritional status of vegetarian and omnivorous
preschool children and their parents in Taiwan. Nutr. Res. (N.Y.)
2008, 28, 430-436.
(22) O’Dell, B. L. Endpoints for determining mineral element require-
ments; an introduction. J. Nutr. 1996, 126, 2342S-2344S.
(23) Haddad, E. H.; Berk, L. S.; Kettering, J. D.; Hubbard, R. W.; Peters,
W. R. Dietary intake and biochemical, hematologic, and immune
status of vegans compared with nonvegetarians. Am. J. Clin. Nutr.
1999, 70, 586S-593S.
(24) Koyyalamudi, S. R.; Jeong, S. C.; Cho, K. Y.; Pang, G. Vitamin B12
is the active corrinoid produced in cultivated white button mushrooms
(Agaricus bisporus). J. Agric. Food Chem. 2009, 57, 6327-6333.
(25) Mann, N.; Li, D.; Guo, X. W.; Kelly, F.; Wilson, A.; Sinclair, A. J.;
Elsworth, G.; Dudman, N. The effect of diet on plasma homo-
cysteine concentrations in healthy male subjects. Eur. J. Clin. Nutr.
1999, 53, 895-899.
(26) Majchrzak, D.; Singer, I.; Männer, M.; Rust, P.; Genser, D.;
Wagner, K. H.; Elmadfa, I. B-vitamin status and concentrations of
homocysteine in Austrian omnivores, vegetarians and vegans. Ann.
Nutr. Metab. 2006, 50, 485-491.
(27) Gilsing, A. M.; Crowe, F. L.; Lloyd-Wright, Z.; Sanders, T. A.;
Appleby, P. N.; Allen, N. E.; Key, T. J. Serum concentrations of
vitamin B12 and folate in British male omnivores, vegetarians and
vegans: results from a cross-sectional analysis of the EPIC-Oxford
cohort study. Eur. J. Clin. Nutr. 2010, 64, 933-939.
(28) Huang, Y. C.; Chang, S. J.; Chiu, Y. T.; Chang, H. H.; Cheng, C. H.
The status of plasma homocysteine and related B-vitamins in healthy
young vegetarians and nonvegetarians. Eur. J. Nutr. 2003, 42, 84-90.
(29) Yen, C. E.; Yen, C. H.; Cheng, C. H.; Huang, Y. C. Vitamin B-12
status is not associated with plasma homocysteine in parents and
their preschool children: lacto-ovo, lacto, and ovo vegetarians and
omnivores. J. Am. Coll. Nutr. 2010, 29, 7-13.
784 J. Agric. Food Chem., Vol. 59, No. 3, 2011
(30) Li, D. Omega-3 fatty acid and non-communicable diseases. Chin.
Med. J. 2003, 116, 453-458.
(31) Diboune, M.; Ferard, G.; Ingenbleek, Y.; Tulasne, P. A.; Calon, B.;
Hasselmann, M.; Saude, P.; Spielmann, D.; Metais, P. Composition
of phospholipid fatty acids in red blood cell membranes of patients in
intensive care units: effects of different intakes of soybean oil,
medium-chain triglycerides, and black-currant seed oil. J. Parenter.
Enter. Nutr. 1992, 16, 136-141.
(32) Crozier, G. L.; Fleith, M.; Traitler, H.; Finot, P. A. Black currant
seed oil feeding and fatty acids in liver lipid classes of guinea pigs.
Lipids 1989, 24, 460-466.
(33) Yamazaki, K.; Fujikawa, M.; Hamazaka, T.; Yano, S.; Shono, T.
Comparison of the conversion rates of alpha-linolenic acid (18:3n-3)
and stearidonic acid (18:4n-3) to longer polyunsaturated fatty acids
in rats. Biochim. Biophys. Acta 1992, 1123, 18-26.
(34) Cho, H. P.; Nakamura, M.; Clarke, S. D. Cloning, expression, and
fatty acid regulation of the human delta-5 desaturase. J. Biol. Chem.
1999, 274, 37335-37339.
(35) Li, D.; Sinclair, A. J.; Mann, N.; Turner, A.; Kelly, F.; Abedin, L.;
Wilson, A.; Ball, M. The association of diet and thrombotic risk
factors in healthy male vegetarians and meat-eaters. Eur. J. Clin.
Nutr. 1999, 53, 612-619.
(36) Li, D.; Ball, M.; Bartlett, M.; Sinclair, A. J. Lipoprotein(a), essential
fatty acid status and lipoprotein lipids in female Australian vegetar-
ians. Clin. Sci. 1999, 97, 175-181.
(37) Rosell, M. S.; Lloyd-Wright, Z.; Appleby, P. N.; Sanders, T. A.;
Allen, N. E.; Key, T. J. Long-chain n-3 polyunsaturated fatty acids
in plasma in British meat-eating, vegetarian, and vegan men. Am.
J. Clin. Nutr. 2005, 82, 327-334.
(38) Kornsteiner, M.; Singer, I.; Elmadfa, I. Very low n-3 long-chain
polyunsaturated fatty acid status in Austrian vegetarians and
vegans. Ann. Nutr. Metab. 2008, 52, 37-47.
(39) Martin, J. F.; Bath, P. M. W.; Burr, M. L. Influence of platelet size on
outcome after myocardial infarction. Lancet 1991, 338, 1408-1411.
(40) O’Malley, T.; Langhorne, P.; Elton, R. A.; Stewart, C. Platelet size in
stroke patients. Stroke 1995, 26, 6995-6999.
(41) Li, D.; Turner, A.; Sinclair, A. J. Relationship between platelet
phospholipid fatty acid and mean platelet volume in healthy men.
Lipids 2002, 37, 901-906.
(42) Cahill, M. R.; Newland, A. C. Platelet activation in coronary artery
disease. Br. J. Biomed. Sci. 1993, 50, 221-234.
(43) Thaulow, E.; Erikssen, J.; Sandvik, L.; Stormorken, H.; Cohn, P. F.
Blood platelet count and function are related to total and cardiovas-
cular death in apparently healthy men. Circulation 1991, 84, 613-617.
(44) Fisher, M.; Levine, P. H.; Weiner, B.; Ockene, I. S.; Johnson, B.;
Johnson, M. H.; Natale, A. M.; Vaudreuil, C. H.; Hoogasian, J. The
effect of vegetarian diets on plasma lipids and platelet levels. Arch.
Intern. Med. 1986, 146, 1193-1197.
(45) Mezzano, D.; Kosiel, K.; Martı́nez, C.; Cuevas, A.; Panes, O.; Aranda,
E.; Strobel, P.; Pérez, D.; Pereira, J.; Rozowski, J.; Leighton, F.
Cardiovascular risk factors in vegetarians. Normalization of hyper-
homocysteinemia with vitamin B(12) and reduction of platelet aggre-
gation with n-3 fatty acids. Thromb. Res. 2000, 100, 153-160.
(46) Hamberg, M.; Svensson, J.; Samuelsson, B. Thromboxanes: a new
group of biologically active compounds derived from prostaglandin
endoperoxides. Proc. Natl. Acad. Sci. U.S.A. 1975, 72, 2994-2998.
(47) Moncada, S.; Vane, J. R. Arachidonic acid metabolites and the
interactions between platelets and blood vessel walls. N. Engl. J.
Med. 1979, 300, 1142-1148.
(48) Raz, A.; Minkes, M. S.; Needlemen, P. Endoperoxides and throm-
boxanes: structural determinants for platelet aggregation and vaso-
constriction. Biochim. Biophys. Acta 1977, 488, 305-311.
(49) Dyerberg, J. Linolenate derived polyunsaturated fatty acids and
prevention of atherosclerosis. Nutr. Rev. 1986, 44, 125-134.
(50) Lands, W. E. M.; Libelt, B.; Morris, A.; Kramer, N. C.; Prewitt,
T. E.; Bowen, P.; Schmeisser, D.; Davidson, M. H.; Burns, J. H.
Maintenance of lower proportions of (n-6) eicosanoid precursors in
phospholipids of human plasma in response to added dietary (n-3)
fatty acids. Biochim. Biophys. Acta 1992, 1180, 147-162.
(51) Stampfer, M. J.; Malinow, M. R.; Willett, W. C.; Newcomer,
L. M.; Upson, B.; Ullman, D.; Tishler, P. V.; Hennekens, C. H. A
Li
prospective study of plasma homocyst(e)ine and risk of myocardial
infarction in US physicians. JAMA, J. Am. Med. Assoc. 1992, 268,
877-881.
(52) Arnesen, E.; Refsum, H.; Bonna, K. H.; Ueland, P. M.; Forde, O. H.;
Nordrehaug, J. E. Serum total homocysteine and coronary heart
disease. Int. J. Epidemiol. 1995, 24, 704-709.
(53) Moleerergpoom, W.; Sura, T.; Sritara, P. Association between serum
homocysteine, folate and B12 concentration with coronary artery
disease in Thai patients. J. Med. Assoc. Thai. 2004, 87, 674-678.
(54) Finkelstein, J. D. Methionine metabolism in mammals. J. Nutr.
Biochem. 1990, 1, 228-237.
(55) Majchrzak, D.; Singer, I.; Männer, M.; Rust, P.; Genser, D.;
Wagner, K. H.; Elmadfa, I. B-vitamin status and concentrations of
homocysteine in Austrian omnivores, vegetarians and vegans. Ann.
Nutr. Metab. 2006, 50, 485-491.
(56) Karabudak, E.; Kiziltan, G.; Cigerim, N. A comparison of some
of the cardiovascular risk factors in vegetarian and omnivorous
Turkish females. J. Hum. Nutr. Diet. 2008, 21, 13-22.
(57) Li, D.; Mann, N.; Sinclair, A. J. A significant inverse relationship
between concentrations of plasma homocysteine and phospholipids
docosahexaenoic acid in healthy male subjects. Lipids 2006, 41,
85-89.
(58) Li, D.; Yu, X. M.; Xie, H. B.; Zhang, Y. H.; Wang, Q.; Zhou, X. Q.;
Yu, P.; Wang, L. J. Platelet phospholipid n-3 PUFA negatively
associated with plasma homocysteine in middle-aged and geriatric
hyperlipaemia patients. Prostaglandins, Leukotrienes Essent. Fatty
Acids 2007, 76, 293-297.
(59) Kulkarni, A.; Mehendale, S.; Pisal, H.; Kilari, A.; Dangat, K.;
Salunkhe, S.; Taralekar, V.; Joshi, S. Association of omega-3 fatty
acids and homocysteine concentrations in pre-eclampsia. Clin. Nutr.
2010, doi: 10.1016/j.clnu.2010.07.007.
(60) Grundt, H.; Nilsen, D. W.; Mansoor, M. A.; Hetland, O.; Nordoy,
A. Reduction in homocysteine by n-3 polyunsaturated fatty acids
after 1 year in a randomised double-blind study following an acute
myocardial infarction: no effect on endothelial adhesion properties.
Pathophysiol. Haemost. Thromb. 2003, 33, 88-95.
(61) Pooya, Sh.; Jalali, M. D.; Jazayery, A. D.; Saedisomeolia, A.;
Eshraghian, M. R.; Toorang, F. The efficacy of omega-3 fatty acid
supplementation on plasma homocysteine and malondialdehyde
levels of type 2 diabetic patients. Nutr. Metab. Cardiovasc. Dis.
2010, 20, 326-331.
(62) Zeman, M.; Zák, A.; Vecka, M.; Tvrzická, E.; Pı́sarı́ková, A.;
Stanková, B. N-3 fatty acid supplementation decreases plasma
homocysteine in diabetic dyslipidemia treated with statin-fibrate
combination. J. Nutr. Biochem. 2006, 17, 379-384.
(63) Huang, T.; Wahlqvist, M. L.; Li, D. Docosahexaenoic acid decreases
plasma homocysteine via regulating enzyme activity and mRNA
expression involved in methionine metabolism. Nutrition 2010, 26,
112-119.
(64) Selhub, J. Homocysteine metabolism. Annu. Rev. Nutr. 1999, 19,
217-246.
(65) Reguera, R. M.; Redondo, C. M.; Pérez-Pertejo, Y.; Balaña-Fouce,
R. S-adenosylmethionine in protozoan parasites: functions, synth-
esis and regulation. Mol. Biochem. Parasitol. 2007, 152, 1-10.
(66) Hamre, M. R.; Clark, S. H.; Mirkin, B. L. Resistance to inhibitors of
S-adenosyl- L-homocysteine hydrolase in C1300 murine neuro-
blastoma tumor cells is associated with increased methionine
adenosyltransferase activity. Oncol. Res. 1995, 7, 487-492.
(67) James, S. J.; Melnyk, S.; Pogribna, M.; Pogribny, I. P.; Caudill,
M. A. Elevation in S-adenosylhomocysteine and DNA hypomethy-
lation: potential epigenetic mechanism for homocysteine-related
pathology. J. Nutr. 2002, 132, 2361S-2366S.
(68) Finkelstein, J. D. The metabolism of homocysteine: pathways and
regulation. Eur. J. Pediatr. 1998, 157, 40S-44S.
(69) Finkelstein, J. D.; Martin, J. J. Methionine metabolism in mammals:
distribution of homocysteine between competing pathways. J. Biol.
Chem. 1984, 259, 9508-9513.
Received for review October 2, 2010. Revised manuscript received
December 2, 2010. Accepted December 2, 2010.